Shock Reduction Using Absolute Calibrated Tissue Oxygen Saturation and Total Hemoglobin Volume Fraction

ABSTRACT

An implantable medical device that includes an optical sensor for providing a signal corresponding to light attenuation by a volume of blood perfused tissue, a control module coupled to the optical sensor controlling the light emitted by the optical sensor, a monitoring module receiving an optical sensor output signal and measuring light attenuation, a tissue electrode for stimulating the volume of blood perfused tissue, a pulse generator coupled to the tissue electrode for delivering electrical stimulation to the volume of blood-perfused tissue, and a processor coupled to the cardiac electrode and the monitoring module and configured to detect an arrhythmia in response to the depolarization signals, compute a tissue oxygenation measurement and control the pulse generator to deliver electrical stimulation to the volume of blood-perfused tissue in response to detecting the arrhythmia, and detect a hemodynamic status of the arrhythmia in response to at least one of a detected rate of tissue oxygenation decline and a detected rate of tissue oxygenation recovery.

RELATED PRIORITY APPLICATION

The present application claims priority and other benefits from U.S.Provisional Patent Application Ser. No. 61/185,831, filed Jun. 10, 2009,entitled “SHOCK REDUCTION USING ABSOLUTE CALIBRATED TISSUE OXYGENSATURATION AND TOTAL HEMOGLOBIN VOLUME FRACTION”, incorporated herein byreference in it's entirety.

REFERENCE TO RELATED APPLICATIONS

Cross-reference is hereby made to the commonly-assigned related U.S.Applications: Attorney Docket Numbers P0034665.03, P0034665.067 andP0034665.07, all entitled “DEVICE AND METHOD FOR MONITORING ABSOLUTEOXYGEN SATURATION AND TOTAL HEMOGLOBIN CONCENTRATION”, to Kuhn et al.;Attorney Docket Numbers P0035554.01, P0035554.02 and P0035554.03, allentitled “TISSUE OXYGENATION MONITORING IN HEART FAILURE” to Cinbis etal.; Attorney Docket Number P0035742.01, entitled “ACTIVE NOISECANCELLATION IN AN OPTICAL SENSOR SIGNAL”, to Kuhn et al.; AttorneyDocket Number P0034899.01, entitled “SHOCK REDUCTION USING ABSOLUTECALIBRATED TISSUE OXYGEN SATURATION AND TOTAL HEMOGLOBIN VOLUMEFRACTION”, to Kuhn et al.; and Attorney Docket Numbers P0035038.01 andP0035038.02, both entitled “ABSOLUTE CALIBRATED TISSUE OXYGEN SATURATIONAND TOTAL HEMOGLOBIN VOLUME FRACTION”, to Kuhn et al., all of which areincorporated herein by reference in their entireties.

TECHNICAL FIELD

The disclosure relates generally to medical devices and, in particular,to an implantable medical device and associated method for controllingthe delivery of cardioversion/defibrillation shocks.

BACKGROUND

Cardiac arrhythmias can be detected and treated by implantablecardioverter defibrillators (ICDs). ICDs typically monitor anintracardiac electrogram (EGM) signal to determine a patient's heartrhythm. When tachycardia or fibrillation are detected, electricalstimulation therapies are delivered, which may include pacing therapiesand/or cardioversion/defibrillation shock therapies. The delivery of ashock therapy can be painful to the patient and uses considerablebattery charge. As such, it is desirable to avoid delivering shocktherapy when unnecessary, for example when the arrhythmia is notlife-threatening and the patient is hemodynamically stable.

An uncalibrated, oxygen saturation index can be determined using animplantable optical sensor detecting two or three light wavelengths formonitoring patient hemodynamics. The uncalibrated oxygen saturationindex can be used in detecting hemodynamically unstable arrhythmias. Theinfluence of motion, optical path length, sensor location, confoundingphysiological events or conditions, and the relationship of anuncalibrated oxygen saturation index to the physiological status of thetissue, e.g. to actual tissue oxygenation, can result in a broadstatistical distribution of the responses of the oxygen saturation indexto both hemodynamically unstable arrhythmias and to normal sinus rhythmresulting in reduced specificity in differentiating between the two. Aneed remains for improved sensors and methods for discriminating betweenhemodynamically stable and unstable arrhythmias. Such discrimination maybe used in controlling the delivery of shock therapies.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic drawing of an implantable medical device (IMD)configured for both monitoring the function of and delivering therapy toa patient's heart.

FIG. 2 is a functional block diagram of an IMD associated with anoptical sensor for monitoring tissue oxygenation.

FIG. 3 is a top, schematic view of an optical sensor according to oneembodiment.

FIG. 4 is a flow chart of a method for operating an optical sensor toobtain photodetector output signals during tissue oxygenationmonitoring.

FIG. 5 is a flow chart of a method for operating an optical sensorduring tissue oxygenation monitoring.

FIG. 6 is a flow chart of an alternative method for using an opticalsensor capable of measuring absolute tissue oxygen saturation formonitoring tissue oxygenation.

FIG. 7 is a flow chart of a method for using an optical sensorincorporated in an ICD system.

FIG. 8 is a flow chart of a method for monitoring patient status andcontrolling arrhythmia therapy delivery.

FIG. 9 is a time-based plot of response curves for calibrated trends inO₂Sat and HbT during induced ventricular fibrillation in a caninesubject.

FIG. 10 is a flow chart of an alternative method for controllingarrhythmia therapy using an optical sensor for monitoring tissueoxygenation.

FIG. 11 is a flow chart of a method for detecting a shockable heartrhythm.

DETAILED DESCRIPTION

In the following description, references are made to illustrativeembodiments. It is understood that other embodiments may be utilizedwithout departing from the scope of the disclosure. In certaininstances, for purposes of clarity, the same reference numbers may beused in the drawings to identify similar elements. As used herein, theterm “module” refers to an application specific integrated circuit(ASIC), an electronic circuit, a processor (shared, dedicated, or group)and memory that execute one or more software or firmware programs, acombinational logic circuit, or other suitable components that providethe described functionality.

In various embodiments described herein, an optical sensor is used tomonitor tissue oxygenation in a measurement tissue volume. Themeasurement volume is the volume of tissue (including blood) in theoptical path of the sensor. The term “tissue oxygenation” as used hereinrefers to the availability of oxygen to a localized tissue volume andthus refers to the availability of oxygenated hemoglobin. The term“total hemoglobin volume fraction” (HbT) refers to the concentration ofred blood cells in a measurement volume carrying hemoglobin and thusrelates to the total hemoglobin concentration as a fraction of ameasurement volume. Stated differently, the total hemoglobin volumefraction, which can be expressed as a percentage, is the volumepercentage of red blood cells carrying oxygenated and deoxygenatedhemoglobin in the measurement volume. Thus a measurement of HbT willinclude contributions from red blood cells present in any arteries,capillaries, and veins which may be present in the measurement volume.Generally speaking, when the availability of oxygen to a body tissue isbeing monitored, the measurement volume of the optical sensor preferablyextends through a uniform tissue volume such that optical sensor signalsused to compute measurements of tissue oxygenation correlate to theabsolute tissue oxygen saturation and HbT in the microcirculation of themeasurement volume.

Absolute tissue oxygen saturation (O₂Sat) is the portion (or percentage)of the total hemoglobin that is in an oxygenated state. Morespecifically, O₂Sat relates to the available hemoglobin binding sitesholding an oxygen molecule. Thus, “tissue oxygenation monitoring” asused herein refers to monitoring both O₂Sat (or an index thereof) andHbT (or an index thereof). Tissue oxygenation monitoring may involvedetermining absolute measurements of O₂Sat and HbT or determining trendsof these measurements or trends of indices of these measurements.

Tissue oxygenation could be determined by a direct measurement of tissueoxygen partial pressure (pO₂). However, measurements of light scatteringby blood chromophores allows measurement of O₂Sat and HbT in themicrocirculation present in the measurement tissue volume to provide anindication of the availability of oxygen to the tissue. O₂Sat measuredusing an optical sensor as described herein is correlated to tissueoxygen partial pressure.

If the availability of oxygen is decreased due to any change in O₂Satand/or HbT, tissue hypoxia may occur or already be present. As such,measurements of O₂Sat and HbT can be used to detect or predict tissuehypoxia without directly measuring the partial pressure of oxygen in thetissue. “Stagnant hypoxia” occurs when inadequate blood flow fails totransport sufficient oxygen to a blood-perfused tissue.

As used herein, “hemodynamic stability” refers generally to cardiacfunction that is adequate to maintain tissue oxygenation measurementsacquired in a blood-perfused body tissue above a predefined threshold.“Hemodynamic instability” refers generally to cardiac function that isinadequate to maintain tissue oxygenation measurements above apredefined threshold. Hemodynamic stability may occur with compromised(reduced) but stable tissue perfusion and thus may be associated withstable (not decreasing) tissue oxygenation measurements even if thetissue oxygenation measurements are relatively lower than a normaltissue oxygenation level. Hemodynamic instability generally correspondsto tissue oxygenation measurements that continue to decrease toward ananoxic state associated with hemodynamic collapse.

FIG. 1 is a schematic drawing of an implantable medical device (IMD) 10configured for both monitoring the function of and delivering therapy toheart H. In FIG. 1, heart H is shown in a partially cutaway viewillustrating right atrium RA, right ventricle RV, left ventricle LV, andcoronary sinus CS.

IMD 10 is shown embodied as an ICD that includes a pulse generator fordelivering electrical stimulation to heart H for use in cardiac pacingtherapies, cardioversion and/or defibrillation. Another example of animplantable medical device in which methods described herein may bepracticed would be a subcutaneous cardioverter/defibrillator havingelectrodes implanted subcutaneously rather than transvenously asdescribed here.

IMD 10 includes hermetically-sealed housing 12 and a connector blockassembly 14 coupled to a right atrial (RA) lead 16, right ventricular(RV) lead 18, left ventricular (LV) lead 20, and optical sensor lead 22.IMD 10 further includes circuitry and a power source, which are locatedwithin housing 12, for controlling the operation of IMD 10. Thecircuitry communicates with leads 16, 18, 20, and 22 through electricalconnectors within connector block assembly 14. A can electrode may beformed on or is a part of the outer surface of housing 12, and may actas an electrode in a unipolar combination with one or more of theelectrodes carried by leads 16, 18 and 20.

Leads 16, 18, and 20 extend from connector block assembly 14 to rightatrium RA, right ventricle RV, and coronary sinus CS adjacent leftventricle LV, respectively, of heart H. Leads 16, 18, and 20 each carryone or more EGM signals, attendant to the depolarization andrepolarization of heart H, for providing pacing pulses for causingdepolarization of cardiac tissue in the vicinity of the distal endsthereof, and for providing cardioversion/defibrillation shocks. Whenprovided, a shock is typically delivered between a combination ofelectrodes carried on RA and RV leads 16 and 18 and the can electrode.

IMD 10 may include an optical sensor 26 along the housing 12 foremitting light into a tissue volume adjacent IMD 10 and detecting lightscattered by the tissue volume for measuring light attenuation by thetissue. The measured light attenuation is used to compute tissueoxygenation measurements as will be described herein.

Alternatively or additionally, an optical sensor 24 may be carried by alead 22 extending from IMD 10. Lead 22 extends from connector blockassembly 14 to optical sensor 24, which is extravascularly-implanted,typically subcutaneously or submuscularly, at a desired tissue site. Inother embodiments, sensor 24 may be carried by a lead and placedtransvenously or transarterially in the blood stream itself. Alead-based sensor may be positioned to transmit light outward throughthe wall of a vessel to monitor oxygenation in adjacent tissue or tomonitor oxygen saturation in the blood stream itself.

Sensor 24 may alternatively be embodied as a wireless sensor, implantedremotely from IMD 10 or worn externally by the patient. Sensor 24provided as a wireless sensor includes telemetry circuitry for wirelesstelemetric communication with IMD 10. Various optical sensorconfigurations that may be implemented in conjunction with an ICD foruse in controlling arrhythmia therapies are generally described in U.S.Pat. Application No. 61/185,824 (Kuhn, et al., Attorney Docket No.P0035038.00), hereby incorporated herein by reference in its entirety.

FIG. 2 is a functional block diagram of an IMD 150 associated with anoptical sensor 180 for monitoring O₂Sat and HbT. IMD 150, which maycorrespond to the ICD shown in FIG. 1, includes (or is coupled to) anoptical sensor 180, which may be incorporated in or on a hermeticallysealed housing of IMD 150, carried by a lead extending from IMD 150, orembodied as a wireless sensor in telemetric communication with IMD 150.IMD 150 further includes sensor input circuitry 162, sensor outputcircuitry 166, and optionally includes reference signal output circuitry164 when a reference photodiode is included in the optical sensor 180for measuring the intensity of emitted light.

Optical sensor 180 generally includes a light source for emitting lightthrough a blood perfused tissue of the patient and a light detector,also referred to herein as a “photodetector”, for generating a signalrepresentative of an intensity of light scattered by the blood perfusedtissue to the light detector. The light passed through the tissue orbloodstream is selected to include four or more wavelengths for use incomputing a volume-independent measure of O₂Sat, from which an absolute,calibrated O₂Sat may be derived. Typically, the intensity of scatteredlight falling in the red part of the visible light spectrum and theinfrared (IR) portion of the light spectrum is measured. The lightscattered by the blood perfused tissue and received by the lightdetector is generally correlated to the oxygenation of the tissue.Changes in tissue oxygenation may be caused by changes in hemodynamicfunction and may thus be used for discriminating between unstable andstable arrhythmias for use in controlling arrhythmia therapy delivery.

Sensor input circuitry 162 is coupled to a light emitting portion 182 ofoptical sensor 180. Light emitting portion 182 includes one or morelight sources for emitting light that includes at least four differentwavelengths. Light sources may emit light at discrete, spaced-apartwavelengths or a single white light source may be used. The measurementof scattered light for at least four different wavelengths allows acalibrated O₂Sat measurement to be obtained. Sensor input circuitry 162provides input signals to the optical sensor 180. In particular, sensorinput circuitry 162 provides the drive signals applied to the lightsources included in light emitting portion 182 to cause controlled lightemission, e.g. controlled intensity, time duration and frequency.

Sensor input circuitry 162 is controlled by sensor control module 168which coordinates the beginning time, duration, and frequency of drivesignals produced by sensor input circuitry 162. Control signals mayinclude a period of no light emission for ambient light measurement.Drive signals may be applied to individual light sources simultaneouslyto cause “mixed” light emission from all light sources. In oneembodiment, the drive signals are applied sequentially to causesequential (i.e., non-simultaneous) light emission by individual lightsources emitting light at spaced apart wavelengths. In this way, a lightdetecting portion 184 of sensor 180 will receive scattered light at anindividual wavelength at any given time during the operation of sensor180. It is recognized that referring to an “individual” or “one”wavelength can include a narrow bandwidth of wavelengths approximatelycentered on, or at least including, the specified individual wavelengthemitted by a light source.

The sequential emission of light wavelengths allows multiple, scatteredlight signals to be sequentially measured for each wavelength. A singleO₂Sat or HbT measurement will require some minimum interval of timecorresponding to the cumulative time durations of each of the separatelyemitted wavelengths. The time-based sequencing of emitted light mayinclude an interval of no light emission to allow for ambient lightmeasurements and correction of the measured light signals for thepresence of ambient light during light emission by the sensor.

In alternative embodiments, the sensor input circuitry 162 is controlledby sensor control module 168 to deliver drive signals simultaneously toeach of the LEDs at separate, unique frequencies. Each LED will emitlight having a signature frequency fluctuation. The detecting portion184 will receive scattered light at all of the wavelengths correspondingto the LED wavelengths simultaneously with each wavelength modulated toa signature frequency. A photodetector signal is then demodulated toobtain the individual wavelength signals.

This frequency multiplexing method of controlling the light emittingportion 182 allows simultaneous light emission and detection such thatchanges in light attenuation by the tissue due to oxygen and hemoglobinchanges in the measurement tissue volume can be measured simultaneouslyfor all of the wavelengths rather than at discrete time intervals. Thisallows for a more instantaneous measurement of O₂Sat and HbT as comparedto the sequentially-acquired signals for separate wavelengths in thetime-multiplexed method of controlling light emission.

The different wavelengths may be modulated at frequencies that are muchgreater than the frequency of ambient light changes. Demodulation of thedetected light signal will reduce or eliminate effects of ambient lightartifact since the low frequency components of the detected light signalcorresponding to ambient light changes will be substantially removedfrom the demodulated photodetector output signal.

Sensor output circuitry 166 receives the photodetector signal from lightdetecting portion 184 and demodulates and digitizes the signal toprovide a digital signal to monitoring module 170. Sensor outputcircuitry 166 may include an analog-to-digital converter and memory fordigitizing an analog output signal from detecting portion 184, providingthe digitized signal to monitoring module 170, storing measurementresults for future retrieval as well as storing calibrationcoefficients.

Monitoring module 170 uses the optical signal to compute avolume-independent measurement of O₂Sat and a measurement of HbT usingthe intensities of the multiple wavelengths measured by detectingportion 184. In some embodiments, a calibrated absolute O₂Sat andcalibrated HbT are derived from the measurements and provided to aprocessor 154 (or other control circuitry) for detection anddiscrimination of arrhythmias.

In particular, the O₂Sat and HbT measurements may be used to detect ahemodynamically stable arrhythmia based on acceptable tissue oxygenationmeasurements obtained during an EGM- or other sensor-based arrhythmiadetection. The detection of a hemodynamically stable arrhythmia could beused to delay a shock therapy. Delaying a shock therapy allows time forless aggressive arrhythmia therapies to be delivered, such asanti-tachycardia pacing therapies to be performed, time for thearrhythmia to spontaneously terminate, and/or time for additionalarrhythmia detection and discrimination algorithms to be performed tocorrectly classify the arrhythmia and select the most appropriatetherapy. The shock therapy may be avoided entirely for the detectedarrhythmia episode if less aggressive therapies are successful orspontaneous termination occurs. Low or decreasing tissue oxygenationmeasurements obtained during arrhythmia detection may confirm the rhythmas a hemodynamically unstable arrhythmia, warranting delivery of a shocktherapy.

As described above, IMD 150 is coupled to electrodes for use in sensingintracardiac EGM signals or subcutaneous ECG signals for detecting anarrhythmia. IMD 150 may include other sensors for sensing physiologicalsignals such as blood pressure, patient activity, patient posture,temperature, or the like. Such sensor signals may be used in combinationwith the monitored O₂Sat and HbT for determining when a therapy isneeded and delivered by therapy delivery module 156. Other sensorsignals may be used to normalize, adjust or separate baseline andperiodic tissue oxygenation measurements according to another monitoredpatient condition, such as local tissue temperature, sensor positionchanges due to changes in patient position, patient activity or thelike.

For example, in one embodiment, a posture sensor 171 is included for usein detecting patient posture. Monitoring module 170 receives a signalfrom posture sensor 171 for use in detecting hemodynamically stablearrhythmias. Multiple tissue oxygenation thresholds may be defined fordifferent patient postures. The posture sensor 171 may be embodied, forexample, as a three-dimensional accelerometer and may be positioned inthe same general location as the optical sensor 180. For example, ifsensor 180 is included in an IMD housing that is implanted in a corebody location, such as along the thorax, posture sensor 171 may also beincluded in the IMD housing to detect different patient postures such asstanding, lying supine, side lying, and so forth. Alternatively, ifoptical sensor 180 is implanted along an extremity, such as the arm, aposture sensor may be implanted in the same general location orincorporated in optical sensor 180 to allow changes in arm position tobe detected (e.g., arm raised or lowered).

Different thresholds based on patient position may be applied to tissueoxygenation measurements for detecting low tissue oxygenation associatedwith hemodynamic instability. As will be further described below, aposture sensor may also be used to control measurement of differentbaseline tissue oxygenation measurements to which a measurement duringarrhythmia detection is compared.

Therapy delivery module 156 includes electrical pulse generationcapabilities for delivering cardiac pacing pulses andcardioversion/defibrillation shocks. Therapy delivery module 156 mayadditionally include a fluid delivery pump for delivering apharmaceutical or biological fluid to the patient and/or provide nervestimulation therapy.

Data acquired by processor 154 relating to O₂Sat and HbT may be storedin memory 152 and/or transferred to a medical device programmer, homemonitor, computer, or other external or bedside medical device viawireless telemetry module 158 for review by a clinician. Processor 154transmits data to and from memory 152, therapy delivery module 156, andtelemetry module 158 via data/address bus 160.

As will be described herein, some embodiments include a referencephotodetector in the light emitting portion 182 of sensor 180. Referencesignal output circuitry 164 may then be included for receiving a lightdetection signal from the reference photodetector and providing areference output signal to sensor control 168 and/or to monitoringmodule 170. In one embodiment, the reference signal output circuitryprovides an emitted light intensity feedback signal to sensor control168 in a feedback control loop to maintain emitted light at eachwavelength at desired relative intensities. Drive signals applied to alight source in light emitting portion 182 can be automatically adjustedto maintain the emitted light within a desired intensity range for eachwavelength measured by the detecting portion 184. In this way, theemitted light spectra is reliably maintained over time promoting theaccuracy of O₂Sat and HbT measurements computed using stored calibrationconstants or assuming stable light emission intensity. Accordinglysensor control 168 may include comparators, analog-to-digitalconvertors, and other logic circuitry for determining if a referenceemitted light intensity signal is within a target range. If not withinthe desired range, the drive signal is adjusted by sensor control 168,e.g., in an iterative manner, until the target range is reached.

In an alternative embodiment, the reference emitted light intensitysignal provided by circuitry 164 is received by monitoring module 170.Monitoring module 170 may use the emitted light intensity and a detectedlight intensity to compute light attenuation at each desired wavelength.The attenuation at each wavelength is used to compute second derivativeattenuation spectra as will be described in greater detail below whichenables derivation of a volume-independent measure of tissue oxygensaturation.

Alternatively, monitoring module 170 uses changes in the emitted lightintensity to adjust a computed O₂Sat value. O₂Sat value may be computedassuming a stable emitted light intensity. The actual emitted lightintensity may be measured and used to adjust a computed O₂Satmeasurement. For example, an initially measured emitted signal intensityand a currently measured emitted signal intensity can be used to adjustor correct an absolute tissue oxygen saturation computed using only thephotodetector signal from detecting portion 184 and calibrationconstants.

In some embodiments, IMD 150 includes electrodes 192 coupled to a pulsegenerator 190 (which may also be incorporated in therapy delivery module156) for delivering electrical stimulation to excitable tissue adjacentto optical sensor 180. Electrical stimulation applied to the tissuevolume that includes the optical pathway of sensor 180 may enhancedetection of inadequate tissue oxygenation. Some methods for controllingarrhythmia therapy may include delivering electrical stimulation to thetissue adjacent optical sensor 180 when an arrhythmia is detected fromsensed EGM/ECG signals. By increasing the metabolic demand of the localtissue, a faster decline in tissue oxygenation will be observed duringhemodynamically unstable arrhythmia than during a hemodynamically stablearrhythmia. Likewise, a quicker recovery of tissue oxygenation will beobserved upon terminating tissue stimulation when an arrhythmia ishemodynamically stable as compared to a hemodynamically unstablearrhythmia.

FIG. 3 is a top, schematic view of an optical sensor according to oneembodiment. It is recognized that numerous sensor configurations may beused for controlling arrhythmia therapy delivery, and the methods formonitoring tissue oxygenation for using in controlling arrhythmiatherapy as described herein are not limited to any particular sensorconfiguration. In general, any optical sensor that acquires thescattered light intensity measurements required to compute avolume-independent measurement of O₂Sat may be used. Examples of otheroptical sensors that may be employed are generally described in U.S.patent application Ser. No. ______, (Kuhn, et al., Attorney Docket No.P0034665.00), hereby incorporated herein by reference in its entirety.

The sensor 100 shown in FIG. 3 includes a light emitting portion 102 anda light detecting portion 104. Light emitting portion 102 includes oneor more light sources 106 positioned to emit light through a lens 103sealed in an opening in hermetically-sealed housing 101. Light sources106 may be embodied as single white light source or multiple lightsources emitting light at separate spaced-apart wavelengths. In oneembodiment, light sources 106 are embodied as light emitting diodes(LEDs) emitting light in the visible (e.g., red) and/or infrared lightspectrum. Suitable light sources include, without limitation,optoelectronic devices such as LEDs, lasers such as vertical cavitysurface emitting lasers (VCSELs), luminescent, phosphorescent orincandescent light sources.

For example, four LEDs are shown which may emit light at separatewavelengths of 680 nm, 720 nm, 760 nm, and 800 nm. Alternatively, thefour LEDs provided as light sources 106 may emit light at 660 nm, 720nm, 760 nm, and 810 nm. In another embodiment, four LEDs are includedemitting light at 720 nm, 760 nm, 810 nm, and 850 nm. In yet anotherembodiment, four LEDs are included that emit light at 720 nm, 760 nm,810 nm, and 890 nm. Any combination of LEDs emitting light at any of thewavelengths mentioned herein may be used. Furthermore, it is recognizedthat the specified wavelengths are approximate and each LED may emit anarrow band of light wavelengths which is approximately centered on, orat least includes, the specified wavelength.

In the embodiment shown, the light emitting portion 102 further includesa reference light detector 110, which may be embodied, for example, as aphotodiode. The light entering an adjacent tissue volume from emittingportion 102 may change over time during chronic use of sensor 100 due,for example, to drift in the photonic output of light source(s) 106and/or changes in the optical properties of the materials encountered bylight emitted by light sources 106 before entering an adjacent tissuevolume. Reference light detector 110 provides an output signal formeasuring or detecting changes in the intensity of the light emitted byemitting portion 102.

The reference light detector 110 output signal can be used in computingor adjusting O₂Sat and HbT measurements as described above inconjunction with FIG. 2. Additionally or alternatively, an output signalfrom reference light detector 110 can be used as feedback signal forcontrolling the drive signals applied to light sources 106 to causelight emission.

In other embodiments, a light detector is not included in the emittingportion. The emitted light intensity is assumed to be stable throughoutthe usable life of the sensor so as not to introduce significant errorin attenuation measurements.

The light detecting portion 104 includes a light detector 108 positionedto receive light through a lens 105 mounted in an opening in housing101. The light detector 108 may be embodied as a photodiode and receiveslight scattered by an adjacent tissue volume. Other components suitablefor use as a light detector include a photoresistor, phototransistor,photovoltaic cell, photomultiplier tube, bolometer, charge-coupleddevice (CCD) or an LED reverse-biased to function as a photodiode. Thedistance 112 between the light sources 106 and the light detector 108will influence the optical path length 114, shown schematically. Greaterspacing (longer distance 112) between the emitting and detectingportions will result in a longer optical path extending deeper in theadjacent tissue volume than relatively shorter distances.

In some embodiments, sensor 100 includes electrodes 120 and 122 fordelivering local electrical stimulation to excitable tissue (e.g.skeletal muscle) adjacent to sensor 100. Local stimulation may beapplied as one or more trains of pulses exceeding the stimulationthreshold of the excitable tissue. The train of pulses may be deliveredat a frequency high enough to cause a fused, tetanic contraction ofskeletal muscle tissue. The duration and/or number of pulse trains maybe fixed or variable. A variable pulse train duration or pulse trainnumber may be terminated when tissue O₂Sat reaches some predeterminedminimum or upon reaching a maximum cumulative pulse train duration,whichever comes first. For detecting hemodynamic stability, the totaltime the tissue is stimulated is expected to be limited to some maximumduration since arrhythmia discrimination is desirable within up to, forexample, approximately 10 seconds in order to enable a quick response ofthe ICD to the arrhythmia.

Local stimulation of the tissue volume that includes the optical pathway114 will increase the oxygen consumption of the tissue, which will bereflected as a decrease in tissue oxygenation measurements. Thisincrease in metabolic demand will accelerate a decline in tissue O₂Satwhen the patient is experiencing a hemodynamically unstable arrhythmia.By accelerating the decline in O₂Sat, a quicker discrimination ofhemodynamically unstable and hemodynamically stable arrhythmias may bepossible, thereby shortening the response time of the ICD.

FIG. 4 is a flow chart of a method 200 for operating an optical sensorto obtain photodetector output signals during tissue oxygenationmonitoring. Flow chart 200 and other flow charts presented herein areintended to illustrate the functional operation of the device, andshould not be construed as reflective of a specific form of software orhardware necessary to practice the methods described. It is believedthat the particular form of software, hardware and/or firmware will bedetermined primarily by the particular system architecture employed inthe device and by the particular detection and therapy deliverymethodologies employed by the device. Providing software to accomplishthe described functionality in the context of any modern medical device,given the disclosure herein, is within the abilities of one of skill inthe art.

Methods described in conjunction with flow charts presented herein maybe implemented in a computer-readable medium that includes instructionsfor causing a programmable processor to carry out the methods described.A “computer-readable medium” includes but is not limited to any volatileor non-volatile media, such as a RAM, ROM, CD-ROM, NVRAM, EEPROM, flashmemory, and the like. The instructions may be implemented as one or moresoftware modules, which may be executed by themselves or in combinationwith other software.

At block 202, a measurement time window is initiated. In variousapplications, tissue oxygenation monitoring may be continuous, periodic,or triggered in response to detecting physiological events monitored bythe medical device, such as detecting arrhythmias. In the example shownin method 200, tissue oxygenation monitoring is performed during aperiodic or triggered measurement window. After initiating themeasurement window, light emission is started at block 204. Lightemission at selected wavelengths may be controlled in a time multiplexedor frequency multiplexed manner or provided as pulsed or continuouswhite or mixed light emission.

At block 206, the electrical output signal generated by thephotodetector is measured. The output signal may be analyzed using anamplitude approach or an integration approach. In the integrationapproach, an integrator is included in the sensor output circuitry forintegrating the photodetector signal, for example using a capacitor. Thesignal may be integrated over fixed time intervals, which may be on theorder of approximately 0.10 to 100 ms for example. The magnitude of theintegrated signal at the end of the fixed time interval is stored as asample data point and corresponds to scattered light received by thelight detecting portion of the optical sensor during the fixed timeinterval. Alternatively, the photodetector signal may be integrateduntil a predetermined integrated signal magnitude is reached and thetime interval required to reach the predetermined magnitude is stored asa sample data point.

In other embodiments, the amplitude of the photodetector signal may bemonitored directly by sampling the signal amplitude throughout themeasurement window. Such sampling may correspond to pulsed light sourceactivation, sequential time intervals of light source activation timesduring time multiplexed light source operation. Alternatively thefrequency may be selected to be greater than the greatest frequencymodulation of an light source in the emitting portion to allow samplingall of frequencies of emitted light in a frequency multiplexedalgorithm.

The measurement window may be set to allow time to acquire a desirednumber of output signal sample points for each of the desiredwavelengths. The photodetector signal amplitude or integrated signalamplitude or time interval continues to be sampled during themeasurement window until it expires as determined at decision step 208.Depending on whether the measurement window is initiated as a periodicmonitoring window or a triggered monitoring window, the duration of themeasurement window may vary from a few seconds to a few minutes orlonger.

After acquiring the desired number of samples, the drive signalscontrolling the light emitting portion may be turned off. Sampled datapoints may be stored and processed for computing O₂Sat and HbT as willbe described further below. The sampled data points may be filtered oraveraged at block 214 to provide smoothing of signal data or removal ofartifact.

At blocks 210 and 212 corrections of sample data may be made to reducethe influence of ambient light and baseline offset. Correctionsperformed in blocks 210 and 212 may be executed before or afterfiltering at block 214. Ambient light may be measured directly bymeasuring the optical signal when the light emitting portion of theoptical sensor is not emitting light. The ambient light contribution maythen be subtracted from the light signal. Baseline offset (sometimesreferred to as the “dark signal” or “dark interval”) is caused bycurrent leakage within the optical sensor electronics that occurs in theabsence of light. Correction for the baseline offset for a given sensorcan be made based on a dark signal or dark interval for that sensor,measured, for example, at the time of device manufacture andqualification testing. If the baseline offset exceeds a desiredthreshold, offset correction may be included at block 212 to subtractthe offset from the incoming signal data. The resulting filtered,corrected sampled signal for each of the wavelengths of interest can beprocessed as will be further described herein for obtaining avolume-independent measurement of O₂Sat and a measurement of HbT forassessing oxygenation of the adjacent tissue volume.

FIG. 5 is a flow chart of a method 300 for operating an optical sensorduring tissue oxygenation monitoring. Method 300 generally correspondsto sensor operation after implantation as will be described inconjunction with FIG. 7. Once the sensor is calibrated and acceptablypositioned, it is enabled for monitoring tissue oxygenation according toa programmed monitoring algorithm. For example, method 300 generallycorresponds to operations performed during a measurement window set on aperiodic or triggered basis as described above in conjunction with FIG.4. The measurement window may also be set as a test measurement windowduring sensor implantation and calibration procedures.

At block 302, the light emitting portion of the sensor is controlled toemit light by applying drive signals to the light source(s). Asdescribed previously, light sources may be controlled to emit light atdifferent wavelengths in a sequential, time-multiplexed manner or in asimultaneous frequency-multiplexed manner or at multiple simultaneous ormixed wavelengths when filtered in the detecting portion. A referencephotodetector included in the light emitting portion provides an outputsignal for measuring the intensity emitted by the sensor at block 308.The output signal is demodulated or otherwise processed to provide anintensity of light emitted for each of the selected wavelengths at whichattenuation will be measured.

At block 304, the emitted light scattered by the tissue volume isdetected by the photodetector in the light detecting portion. Thedetecting portion provides an output signal corresponding to theintensity of light received. The output signal is demodulated orotherwise processed to provide an intensity of light received for eachof the selected wavelengths.

At block 306, the attenuation spectrum is measured. In one embodiment,the attenuation of four wavelengths in the red to infrared spectrum ismeasured. The attenuation of the four different wavelengths may bemeasured using sequential detection of the different wavelengths by thephotodetector when a time multiplexed light emission control algorithmis used. Alternatively, measurement of the four different wavelengthsmay involve demodulation of simultaneously detected light at the fourdifferent wavelengths when a frequency multiplexed light emissioncontrol algorithm is used. In other embodiments, remitted light from awhite light source or simultaneously emitting single wavelength sourcesmay be filtered to obtain the four different wavelength attenuationsignals. In still other embodiments, LEDs configured for narrow-bandlight detection may be used to detect the four separate wavelengths.

The attenuation for a given wavelength (λ) can be measured as thenegative logarithm of the ratio of the emitted light intensity (i_(in))to the remitted light intensity (i_(out)):

A(λ)=−log(i _(in) /i _(out))_(λ)  [1]

wherein i_(in) can be measured using a reference photodetector in thelight emitting portion of the sensor and i_(out) is measured using theoutput signal of the light detecting portion for a given wavelength.Remitted light is the light that is scattered by the adjacent tissuevolume and received by the light detecting portion of the opticalsensor. The term “attenuation” measurement as used herein generallyrefers to a measure of the attenuation of light due to absorption andscattering by tissue along the optical path of the sensor. The measuredattenuation may therefore not be an exact measurement of the actuallight absorption by the tissue volume since light reflections andscattering may cause attenuation of the remitted light intensity notattributed to actual light absorption by the tissue.

Alternatively, the emitted intensity i_(in) for each wavelength ismeasured prior to implantation, e.g., at the time of manufacture, andassumed to be sufficiently stable throughout the usable life of thesensor as to not cause significant measurement error. In this case, areference photodetector may be eliminated from the light emittingportion of the sensor and thereby reduce overall size and complexity ofthe sensor. One method for measuring the emitted intensity prior toimplantation uses the light detecting portion to measure the remittedlight when the sensor is positioned within a calibrated reflectivehousing. The construction of the emitting portion is designed tominimize or prevent drift in the emitted light intensity over time.Design considerations include minimizing the distance between the tissueand the photonic surfaces of the LEDs (or other light emittingoptoelectronic devices included in the emitting portion).

The attenuation for four wavelengths is determined to allow the secondderivative with respect to wavelength of the attenuation spectra at thetwo intermediate wavelengths to be computed. This determination ofsecond derivatives at two intermediate wavelengths allows forcomputation of a ratio fo the two second derivatives as a scaled secondderivative. By properly selecting the intermediate wavelengths, a scaledsecond derivative is an oxygen-dependent and volume-independent ratioand therefore provides a measure of O₂Sat. At block 310, the attenuationmeasurement for each intermediate wavelength out of the four detectedwavelengths is converted to a second derivative (D″), expressedgenerally as:

D″(λ_(i))=A(λ_(i+1))−2A(λ_(i))+A(λ_(i−1))  (2)

wherein A(λ_(i)) is the light attenuation, measured according toEquation 1 above, at the wavelength for which the second derivative isbeing computed, A(λ_(i+1)) is the attenuation at the next higherwavelength and A(λ_(i−1)) is the attenuation at the next lowerwavelength of the four wavelengths. Equation 2 assumes equal spacingsbetween the four wavelengths. When unequal spacings are used, adifferent equation for the second derivative with respect to wavelengthis required to account for the different wavelength spacings.

The second derivative of a selected intermediate wavelength is scaled bythe other computed second derivative at block 312. In one embodiment,the attenuation is measured for wavelengths at 680 nm, 720 nm, 760 nm,and 800 nm. The second derivatives of the attenuation spectra arecomputed at 720 nm and 760 nm and the second derivative at 720 nm isscaled by the second derivative at 760 nm. The scaled second derivative(SD″) of the 720 nm attenuation can be expressed as

SD″=D″(720)/D″(760)  (3)

This SD″(720) is dependent on tissue oxygen saturation and independentof the total hemoglobin and optical path length. The reduced dependenceon total hemoglobin and optical path length is expected to reduce theeffects of motion artifact on the oxygen measurement.

Once the scaled second derivative is obtained, the stored calibrationdata is used at block 314 to derive the absolute O₂Sat. The secondderivative for attenuation at 720 nm wavelength (as well as 760 nm) isdependent on oxygen saturation and total hemoglobin. Thus, at block 316,HbT may be determined knowing the D″(720), or D″(760), with respect towavelength, the derived absolute O₂Sat, and the stored calibration data.

Tissue oxygenation, as defined herein, is a function of both tissueO₂Sat and HbT. Depending on the particular tissue oxygenation monitoringapplication, the derived O₂Sat and HbT may each be used separately in amonitoring algorithm or combined to determine a tissue oxygenation indexused to monitor a patient's status and/or detect a physiologicalcondition. At block 322, a tissue oxygenation index may be computed as afunction of O₂Sat and HbT. For example, a tissue oxygenation index maybe a weighted combination of the O₂Sat and HbT measurements. In oneembodiment, a tissue oxygenation index is computed as:

TOI=0.8O₂Sat+0.2HbT  (4)

It is recognized that other weighting factors may be used and theselected weighting factors may even be tailored to an individual patientand a particular monitoring/detection algorithm.

Thus, a tissue oxygenation index computed using absolute measurements ofO₂Sat and HbT can be available on a continuous or periodic basis in anambulatory patient. The TOI and/or the individual calibrated values ofO₂ Sat and HbT may be used for tracking a patient's baselineoxygenation, changes in patient status and in detecting hemodynamicallyunstable arrhythmias.

The absolute values of O₂ Sat, HbT and the TOI computed using thecalibrated absolute values of O₂ Sat and HbT are computed and stored bythe ICD. Additionally, differences between each of these oxygenationmeasures and a baseline or other earlier corresponding measure may becomputed and stored as calibrated trended variables. As such, inaddition to storing the absolute values, trended values of each of theoxygenation measurements may be stored as changes in the absolute valuesover time, referred to as dO₂ Sat, dHbT or dTOI, which each representthe difference between a current measurement and a previous measurementof the same calibrated measurement.

Alternatively or additionally, non-calibrated values and trends of theoxygenation measurements may be determined and stored. Since sensorcalibration can be time consuming and adds to computational burden forcomputing a calibrated measurement, it may be desirable to computenon-calibrated values and trends of oxygenation measurements withoutconversion of those measurements to an absolute value. For example, ascaled second derivative of a properly selected wavelength, SD″(λ), is avolume-independent measure of O₂Sat and may be computed as an index ofO₂Sat without conversion to a calibrated measurement. Likewise, D″(λ),which is volume and oxygen dependent, can provide an index of HbTwithout conversion to a calibrated measurement. Each of theseuncalibrated oxygenation measurements may be used individually asbaseline indices of tissue oxygenation or combined in a computation of aTOI, such as a weighted linear combination of the uncalibratedmeasurements similar to Equation (4) above.

The uncalibrated measurements of SD″(λ), D″(λ), and a TOI computed usingSD″(λ) and D″(λ) may be determined and stored at device implant for useas baseline measurements and measured during patient monitoring formonitoring patient status and for use in detecting hemodynamicallyunstable arrhythmias and controlling device therapies. Trends in each ofthe uncalibrated measurements over time, referred to as dSD″(λ), dD″(λ),and dTOI, may also be determined and stored as the difference between acurrent uncalibrated measurement and a previous correspondingmeasurement. In summary, various algorithms for monitoring a patient'stissue oxygenation status, detecting hemodynamically stable and unstablearrhythmias and controlling arrhythmia therapy may utilize calibratedmeasurements (O₂ Sat and HbT), trends in the calibrated measurements(dO₂Sat and dHbt), uncalibrated measurements (SD″(λ) and D″(λ)), and/ortrends in the uncalibrated measurements (dSD″(λ) and dD″(λ)).

The oxygen saturation measurement derived from a scaled secondderivative is a volume-independent measurement and is therefore expectedto have reduced susceptibility to motion artifact, which could alter theoptical pathway and thus alter the measurement volume. However, someembodiments may utilize the measured total hemoglobin volume fraction,which is dependent on the measurement volume, to filter or blank tissueoxygenation monitoring during periods in which HbT is out of a normalrange, which may be due to motion or activity of the patient.

Accordingly, in one embodiment, the measured HbT is compared to anacceptable range, e.g. between approximately 1% and approximately 25%,at block 318. If HbT is out of the acceptable range, tissue motion maybe causing erroneous HbT measurements. At block 320, the tissueoxygenation measurement is blanked or otherwise deemed invalid based onthe out-of-range HbT measurement. For example, patient activity mayresult in oscillatory movements that produce a signal that isintermittently in and out of the acceptable range. Intervals in whichthe HbT measurement is out-of-range may be blanked for determining atissue oxygenation index. During intervals in which the HbT measurementis in range, the tissue oxygenation index is computed at block 322. WhenHbT is out of range, the absolute tissue oxygen saturation measurementmay also be ignored or still be determined and stored.

FIG. 6 is a flow chart of an alternative method 400 for using an opticalsensor capable of measuring absolute tissue oxygen saturation formonitoring tissue oxygenation. At block 402, control signals are appliedto drive circuitry to control the emission of light from the lightemitting portion of the optical sensor.

In one embodiment, a reference photodetector is included in the lightemitting portion to provide a reference signal measuring the emittedlight. The intensity of the emitted light may be controlled using areference feedback signal as indicated by block 404. In other methods, areference photodetector is used to measure the emitted light intensityfor computing the attenuation of each wavelength using Equation 1 above.In method 400, the emitted light intensity is measured using thereference photodetector for controlling light emission such that theemitted intensity (i_(in)) at each of the wavelengths used forattenuation measurements is maintained within a specified range.

An emitted light reference signal measured at block 404 using thereference photodetector output signal is provided as feedback to thecontrol module controlling light emission at block 402. Drive signalsapplied to the light emitting portion may be adjusted in response to theemitted light reference signal to maintain the emitted light intensitywithin a target range for each wavelength selected for attenuationmeasurements.

When the emitted light is controlled to be maintained within a specifiedrange, the emitted light intensity (i_(in)) in the attenuation Equation(1) above becomes a constant. Manipulation of the second derivativeEquation (2) above results in a modified second derivative equation:

D″(λ_(i))_(modified) =C _(i)−log(i _(out))_(λi+1)+2 log(i_(out))_(λi)−log(i _(out))_(λi−1)  (5)

which may be rewritten as:

D″(λ_(i))_(modified) =C _(i)+log {(i _(out))_(λi) ²/((i_(out))_(λi+1))(i _(out))_(λi−1))}  (6)

The term C_(i) for a given wavelength λ_(i) becomes a calibrationconstant. Thus, a modified scaled second derivative may be computedusing only the detecting portion output signal and the calibrationconstants C_(i) determined for each of the measured wavelengths. In thecase where there is no reference measurement for emitted lightintensities at each wavelength, but the drive signal to the lightsources is controllable, the constants Ci are predetermined functions ofthe drive signal. Note that the above Equation 6 is written for equalwavelength spacing and will include more terms for non-equal wavelengthspacing.

The scattered light is detected by the optical sensor at block 406 andused to compute the modified second derivatives at block 408 at two (ormore) intermediate wavelengths. The modified second derivatives needonly be computed for two intermediate wavelengths being used to computeO₂Sat and HbT.

A simplified scaled second derivative may be used as an estimate oftissue oxygen saturation in which the C, constants are ignored in theabove equations. A simplified scaled second derivative may take the formof:

$\begin{matrix}{{SD}^{''} = \frac{{- {\log \left( i_{out} \right)}_{{\lambda \; i} + 1}} + {2{\log \left( i_{out} \right)}_{\lambda \; i}} - {\log \left( i_{out} \right)}_{{\lambda \; i} - 1}}{{- {\log \left( i_{out} \right)}_{{\lambda \; i} + 2}} + {2{\log \left( i_{out} \right)}_{{\lambda \; i} + 1}} - {\log \left( i_{out} \right)}_{\lambda \; i}}} & (7)\end{matrix}$

This simplified scaled second derivative may be useful for measuring anuncalibrated, index of O₂Sat at block 410. A corresponding uncalibratedindex of HbT may be computed at block 412 using the simplified secondderivative computed using Equation 6. The O₂Sat and HbT indices may beused individually or combined in a TOI computed as a function of both atblock 414.

In addition or alternatively to using the emitted light reference signalas feedback to control light emission, the emitted light referencesignal may be used by the monitoring module to adjust the computedmodified second derivatives at block 408. Shifts in the intensity of theemitted light may be accounted for by introducing a correction term inthe equation used to compute the modified second derivative.Accordingly, an adjusted modified second derivative for a selectedintermediate wavelength used to compute absolute oxygen saturation mightbe computed using:

D″(λ_(i))_(modified) =C _(i)−log(i _(out)+CT)_(λi+1)+2 log(i_(out)+CT)_(λi)−log(i _(out)CT)_(λi−1)  (8)

wherein CT is a correction term determined for each wavelength using theemitted light reference signal and is used to adjust the remitted lightintensities i_(out) for each wavelength. The CT may be a positive ornegative value.

In the methods described herein for monitoring patient status, sensorstatus, detecting hemodynamically unstable arrhythmias and controllingdevice therapies, the modified second derivative computations may besubstituted for second derivative computations used in derivingvolume-independent indices of O₂Sat and indices of HbT.

FIG. 7 is a flow chart of a method 250 for using an optical sensorincorporated in an ICD system. At block 252 of method 250, the opticalsensor is calibrated using control samples, for example in an in vitroblood circuit, having known oxygen saturation and total hemoglobinconcentration. The calibration method may be used to generate a look-uptable. A look-up table of values relating measurements computed from thephotodetector output signal and the known O₂Sat and HbT may be stored inthe device memory. The look-up table can then be used to derive absoluteO₂Sat and Hbt values from an optical sensor measurement as will befurther described below.

Alternatively, calibration methods may include curve-fitting methods tosolve for coefficients defining best-fit curves to the calibration data.In one embodiment, the absolute tissue oxygen saturation is defined by:

O₂sat=Ae ^(B(SD″(λ) ^(i) ⁾⁾ +C  (9)

wherein SD″ is a scaled second derivative of the attenuation spectra ata selected intermediate wavelength (λ_(i)) emitted and detected by theoptical sensor. As described above, a scaled second derivative of theattenuation spectra at a selected wavelength is determined by themonitoring module using the photodetector signal. The scaled secondderivative is the ratio of the second derivative with respect towavelength of the attenuation spectra at a selected wavelength λ_(i) tothe second derivative of the attenuation spectra at another selectedwavelength used for scaling. By properly selecting the wavelength λ_(i)and the other wavelength used for scaling, the scaled second derivativeis an oxygen-dependent and volume-independent ratio. The coefficients A,B and C are determined through best-fit analysis of measurements of thescaled second derivative for calibration samples having known oxygensaturation.

The total tissue hemoglobin volume fraction can be defined by theequation:

HbT=[M(100−O₂Sat)^(N) +L]*[(D″(A)_(λi) /dλ)/SF]  (10)

wherein M, N, and L are coefficients determined during calibration andD″(λ)_(λi)/dλ is the second derivative of the attenuation spectra withrespect to wavelength at the selected intermediate wavelength λ_(i). Thesecond derivative of the attenuation spectra with respect to wavelengthat a given wavelength is also referred to generally herein as D″(λ).D″(λ) is measured for samples containing known total hemoglobin volumefraction and known oxygen saturation. The calibration coefficients M, Nand L may then be computed for a best-fit of the measured secondderivative values and known O₂ Sat and HbT. Alternatively, the measuredsecond derivative values and known O₂Sat and HbT may be used to generatea look-up table for converting the measured second derivative values toHbT.

SF is a spacing factor which may be used to adjust for anemitting-to-detecting portion spacing that may be different duringmeasurements than that used during calibration. Since the HbTmeasurement is dependent on both O₂Sat and the measurement volume, andmeasurement volume is dependent on the optical pathway defined at leastin part by the spacing between the emitting and detecting portions, theHbT measurement needs to be corrected for changes inemitting-to-detecting portion spacing. For example, the sensor may becalibrated using a nominal emitting-to-detecting portion spacing,however when multiple emitting and/or detecting portions are selectablein a sensor or combination of sensors, the spacing may be differentduring monitoring than that used during calibration. As such, a spacingfactor corresponding to selectable emitting and detecting portions maybe stored and used to correct the HbT measurement when a differentspacing is used during monitoring than during calibration.

At block 254, the sensor is positioned at a desired implant site (orexternal site in the case of an external device to be worn by thepatient). A test measurement is performed at block 256. The absoluteO₂Sat and HbT are determined from the sensor output signal using thestored calibration data. The measured values are compared to anacceptable measurement range at block 258. This comparison may beperformed manually or automatically using a programmed range stored inthe medical device memory. An acceptable measurement range generallycorresponds to an expected physiological range for O₂Sat and HbT. Forexample, an acceptable range for tissue O₂Sat might be defined to bebetween approximately 80% and 90%, but may be determined clinically. Anacceptable range for HbT might be defined to be between approximately 1%and 25%. These ranges may vary depending on the type of tissue adjacentto the sensor, the heterogeneity of the tissue, the oxygenation state ofthe patient and other factors. The acceptable measurement range may bedefined nominally or tailored to a given patient.

If the tissue oxygen saturation exceeds a predefined expected range, forexample greater than approximately 90%, the sensor may be in a positionthat results in arterial blood strongly contributing to the tissueoxygen saturation measurement. If the monitoring application isconcerned with measuring tissue oxygenation, e.g. in skeletal muscle,rather than arterial oxygen saturation, the sensor may be repositionedat block 264.

Likewise, if the oxygen saturation is too low, for example less thanapproximately 80%, the sensor may be in a position that results invenous blood strongly contributing to the oxygen saturation measurement.If the absolute oxygen saturation falls below an expected physiologicalrange for the particular sensing application, the sensor may berepositioned at block 264.

If the total hemoglobin is less than a predetermined range, for exampleless than approximately 1%, the sensor may be improperly positionedagainst the tissue (poor tissue contact) or in a position over anon-tissue medium or low or non-perfused tissue. For example, if thesensor is positioned over fat, scar tissue, clear body fluids, or otherimplanted medical device components, the total tissue hemoglobinconcentration may be below a normal physiological range for perfusedtissue. A total tissue hemoglobin of greater than an acceptablephysiological range, for example greater than approximately 25%, mayindicate blood pooling in the measurement volume beneath the sensor orother sensor measurement error. If the HbT test measurement is outside apredefined acceptable range, the sensor may be repositioned at block264. Instead of repositioning the sensor at block 264, a selectedoptical path may be changed when multiple light emitting and detectingpairs are available to select from for monitoring tissue oxygenation.

Once the O₂Sat and HbT measurements are confirmed to be in an acceptablephysiological range for the tissue being monitored, at block 258, atissue uniformity index may be determined at block 260. A tissueuniformity index is determined by utilizing at least two differentemitting-to-detecting portion spacings. Accordingly at least twodifferent combinations of light sources and light detectors at twodifferent spacings must be available, on the same or different opticalsensors, positioned adjacent a target tissue volume.

When at least two different spacings are available, the absolute tissueoxygen saturation is measured using the two different spacings andcompared. A tissue uniformity index may be computed based on thedifference between two or more measurements performed using differentemitting-to-detecting portion spacing. Each measurement would eachinvolve different measurement volumes defined by different measurementpathways extending through the tissue. For example, a relatively greateremitting-to-detecting portion spacing would result in greater depth ofthe measurement pathway and measurement volume.

If the difference between two measurements is small, the tissue isrelatively homogeneous and uniform through the depth of the largermeasurement volume. If the difference between two measurements is large,the tissue is more heterogeneous or non-uniform in oxygenation. Athreshold for detecting uniform, homogenous versus non-uniform,heterogeneous tissue volumes may be selected according to a particularapplication. Detection of heterogeneous tissue may warrant repositioningof the sensor. A tissue uniformity index may indicate the mostappropriate emitter-to-detector spacing for measuring within a desiredtissue volume and therefore guide selection of light sources and lightdetectors when multiple combinations are available.

In summary, the initial O₂Sat, HbT, and tissue uniformity measurementscan be used individually or in combination to decide if the sensorposition is acceptable at block 262. If not the sensor may berepositioned at block 264. Instead of repositioning the sensor whenunacceptable tissue uniformity or HbT or O₂Sat measurements areobtained, a different optical path may be selected at block 264 byselecting a different combination of light source(s) and light detectorwhen available. For example, multiple light sources and light detectorsmay be available in one or more sensors to allow selection of differentoptical paths.

If the sensor position is acceptable, the sensor is fixed at the desiredsite, and baseline O₂Sat and HbT measurements may be acquired and storedat block 266 according to the needs of the particular sensingapplication. Baseline measurements may be acquired for comparison tofuture measurements, for use in learning algorithms performed duringclinical interventions or during spontaneously occurring arrhythmias foruse in setting thresholds for detecting arrhythmias and discriminatinghemodynamically stable and unstable forms of arrhythmias, or forinitiating continuous monitoring of the tissue O₂Sat and HbT, i.e.tissue oxygenation, for monitoring patient status.

At block 268 preliminary detection thresholds are set for discriminatinghemodynamically stable arrhythmias from hemodynamically unstablearrhythmias. A detection threshold may be set based on a percentagechange or other defined interval from the baseline measurements.

When HbT and/or O₂Sat measurements are out of an acceptable range and adifferent emitting-to-detecting portion spacing is not available orrepositioning at block 264 is not possible, or otherwise not performed,baseline measurements may still be stored at block 266 and used forsetting patient-specific thresholds at block 268. Patient-specificthresholds of HbT and O₂Sat, or a tissue oxygenation index computed fromthe HbT and O₂Sat measurements, may be defined and stored for use indetecting and discriminating arrhythmias.

For example, if the O₂ Sat measurement is low, e.g. <80%, the sensor maybe located near a vein and the contribution of the venous blood in theoptical path may be causing the lower measurement. In this case, achange in O₂Sat and HbT during a hemodynamically unstable arrhythmia maybe reduced compared to a measurement that is obtained over a capillarybed. Likewise if a high arterial blood contribution is present in themeasurement due to the sensor being located over an artery, the baselineO₂Sat will be higher than when positioned over a capillary bed. A changein O₂Sat during a hemodynamically unstable arrhythmia may again be lowerthan when the sensor is over a capillary bed. As such, thresholdsrelating to O₂Sat and HbT and thresholds relating to changes in O₂Satand HbT that are used for detecting hemodynamically unstable arrhythmiasmay be adjusted according to baseline measurements. For example, athreshold change in O₂Sat for detecting ventricular fibrillation may belowered when the initial baseline O₂Sat measurement is lower (highervenous contribution) or higher (higher arterial contribution) than anexpected baseline measurement (or acceptable measurement range)corresponding to positioning over a capillary bed.

After setting preliminary thresholds at block 268, arrhythmia inductionis performed at block 270. Current clinical practice includes inducing aventricular fibrillation (VF) episode during an ICD implantationprocedure to verify an acceptable defibrillation shock threshold. Afterinducing VF, the optical sensor response is assessed at block 272. Forexample measurements obtained continuously or a predefined time pointsat baseline, episode onset, and during the episode may be compared toassess the change in O₂Sat, HbT, and/or a tissue oxygenation indexcomputed from the measured O₂Sat and HbT. Changes in the oxygenationmeasurements and comparisons of the measurements to the preliminarythresholds set at block 268 can be used to determine if an appropriatedetection of a hemodynamically unstable arrhythmia is made during theinduced VF.

Adjustment of the preliminary threshold(s) may be made based on thesensor response. Adjustments may be made manually or automatically bythe device. If an appropriate detection is made, the preliminarythresholds are accepted and set as the detection thresholds at block274. If not, the thresholds are adjusted appropriately based on theoxygenation measurements during the induced VF episode. If anappropriate detection is made, but a large difference exists between thethreshold(s) and the oxygenation measurements, the threshold may beadjusted to provide greater specificity to VF detection.

FIG. 8 is a flow chart of a method 340 for monitoring patient status andcontrolling arrhythmia therapy delivery. At block 341, oxygenationmonitoring is enabled. Oxygenation monitoring may be enabled at the timeof device implantation based on acceptable sensor positioning, baselinemeasurements, and sensor response to an induced arrhythmia episode.

Tissue oxygenation measurements may be performed on a periodic basis forassessing patient status, sensor function, and resetting baselinemeasurements or adjusting detection thresholds. Additionally, tissueoxygenation measurements are performed on a triggered basis upondetecting a concerning arrhythmia episode. At block 342, the devicedetermines if it is time to perform periodic measurements, e.g. based onexpiration of a periodic timer. Periodic measurements may be obtained atany desired time interval, for example hourly, daily or weekly. Periodictime measurements may be adjusted automatically or manually ifmeasurements are desired on a more or less frequent basis. For example,if a change greater than a predetermined percentage or predefined rangeis detected since a previous measurement, the frequency of periodicmeasurements may be increased to allow closer monitoring of patientstatus.

If it is time for performing periodic measurements, the ICD confirms thepatient is in normal sinus rhythm at block 343. Normal sinus rhythm canbe verified based on regular EGM event intervals (P-P intervals and/orR-R intervals) occurring at a rate less than a tachycardia detectionrate. If normal sinus rhythm is not verified at block 343, method 340advances to block 352 to determine if the rhythm is a concerning rhythmthat requires tissue oxygenation monitoring. If normal sinus rhythm ispresent, the oxygenation measurements are performed at block 344.Performing tissue oxygenation measurements involves computing theuncalibrated SD″(λ) and D″(λ) values. These values may be stored asindices of O₂Sat and HbT or converted to calibrated absolute O₂Sat andHbT measurements using stored calibration data when available. A TOI maythen be computed using the uncalibrated SD″(λ) and D″(λ) values and/orthe calibrated O₂Sat and HbT.

At block 346, the measurements are stored and may be used to determine apatient status. For example, a patient tissue oxygenation status may beindicated as hypoxic or normal based on the oxygenation measurements. Ahypoxic status may warrant more frequent patient monitoring orgenerating a warning provided to the patient or to a clinician.

A patient posture signal may be provided as input when determiningpatient status as indicated by block 355. For example, in oneembodiment, an accelerometer is used for detecting a patient position(or optical sensor position). The patient position is used to storedifferent tissue oxygenation measurements according to patient positionand for determining different baseline tissue oxygenation measurementsaccording to patient position. Detection of a patient status may takeinto account both the patient (or sensor) position and the oxygenationmeasurement.

At block 348, the oxygenation measurements may be used to determine andstore a status of the optical sensor. If either of the O₂Sat or HbTmeasurements (or SD″(λ) and D″(λ)) are out of the acceptable measurementrange, the sensor status may be indicated as unreliable. Tissueoxygenation measurements may be temporarily or permanently disabledbased on out of range measurements.

The oxygenation measurements performed at block 344 and determination ofsensor status at block 348 may be analogous to the measurements andcomparisons performed at the time of device implant (with the exceptionof an induced arrhythmia) as discussed in conjunction with FIG. 7. Inother words, comparisons to acceptable measurement ranges and a measuredtissue uniformity index may be used to select a new combination of lightsource(s) and light detectors (when available) to change the opticalpath of the sensor, update stored baseline measurements, and/or adjustthe detection thresholds applied to the oxygenation measurements asindicated at block 350.

When a concerning arrhythmia is detected at block 352, oxygenationmeasurements are performed at block 354 and stored as arrhythmia episode“onset” measurements. An arrhythmia may be initially detected based onEGM sensing. Arrhythmia detection methods may include EGM event intervaland/or EGM morphology analysis. Tissue oxygenation monitoring may beinitiated at block 354 in response to any arrhythmia detection or inresponse to certain types of arrhythmia detection defined as“concerning” arrhythmias.

In one embodiment, a “concerning” arrhythmia is an EGM-based arrhythmiadetection associated with a fast ventricular rate falling in a fastventricular tachycardia (VT) or a VF detection rate zone. A “concerning”arrhythmia may also be defined to include an arrhythmia that cannot bediscriminated between an atrial arrhythmia (supraventricular arrhythmia)and ventricular arrhythmia, e.g. due to approximately equal atrial andventricular rates with 1:1 correspondence between atrial and ventricularevents. Such arrhythmias may originate in the atria in which case aventricular shock therapy is not needed. In other embodiments, a“concerning” arrhythmia may be any arrhythmia exceeding a predeterminedrate, in particular any arrhythmia detected in response to a fastventricular rate which may be a hemodynamically unstable, potentiallylethal arrhythmia.

In some cases, oversensing of the EGM/ECG signal (e.g. T-wave sensing)or other lead related issues (e.g. internal short) may cause erroneoussensing and detection of an arrhythmia. Tissue oxygenation monitoringcan be used to confirm hemodynamic stability when arrhythmia detectioncriteria are met due to erroneous sensing and thereby reduce theoccurrence of unnecessary shocks.

Oxygenation measurements are used to determine if the concerningarrhythmia is hemodynamically unstable. If the patient is experiencing ahemodynamically unstable ventricular arrhythmia, a shock therapy may bedelivered according to a programmed schedule (or immediately) to restorestable hemodynamic function as quickly as possible. When a fastventricular arrhythmia is detected but the patient remainshemodynamically stable, a shock therapy may be delayed or withheld toallow spontaneous termination of hemodynamically stable arrhythmia,additional arrhythmia discrimination algorithms and/or less aggressivearrhythmia therapies, such as anti-tachycardia pacing therapies to bedelivered in an attempt to avoid delivery of a shock.

At block 354, O₂Sat and HbT are measured. Alternatively, during anarrhythmia episode, the uncalibrated measurements may be computedwithout conversion to absolute, calibrated values. During an arrhythmiaepisode, the use of the uncalibrated values (SD″(λ) and D″(λ)) may saveprocessing time allowing a trend in tissue oxygenation measurements thatindicates poor oxygenation (and hemodynamic compromise) to be detectedmore quickly.

If the oxygenation measurements are still within the predeterminedacceptable measurement range, indicating proper sensor operation, themeasurements are compared to baseline oxygenation measurements inconjunction with the stored detection thresholds.

Stored detection thresholds applied to tissue oxygenation measurementsat block 358 are defined for detecting the hemodynamic status of thepatient. The stored thresholds correspond to discriminating betweenacceptable tissue oxygenation and low tissue oxygenation that may leadto tissue hypoxia or anoxia.

As such, tissue oxygenation measurements are used in method 340 todetermine the hemodynamic status of an arrhythmia already detected usingEGM/ECG signals, alone or in combination with other sensor signals.Tissue oxygenation measurements are not used as a primary signal forarrhythmia detection. It is contemplated, however, that in otherembodiments, the tissue oxygenation measurements may be combined withthe EGM/ECG signals and/or other sensor signals to make the initialarrhythmia detection in a multi-parameter arrhythmia detection analysis.

If the onset oxygenation measurements represent a large change frombaseline, the patient may already be in a state of hemodynamiccompromise. For example the patient may be experiencing a slow onsetarrhythmia in which hemodynamic collapse has already begun or occurred.The concerning arrhythmia is detected as hemodynamically unstable atblock 360. A shock therapy may be delivered immediately at block 361 (oraccording to a programmed schedule).

A detection threshold applied to onset oxygenation measurements may bedefined separately from detection thresholds used later in the episode.For example a relatively large change in tissue oxygenationmeasurements, such as an approximately 50% drop in TOI, may be requiredto immediately deliver a shock in response to onset tissue oxygenationmeasurements.

If the detection threshold criteria defined for the onset oxygenationmeasurements are not met at block 358, an default stable hemodynamicstatus is detected at block 359 (since it may be too early afterarrhythmia detection to ascertain the hemodynamic stability of thearrhythmia) and shock therapy is not yet warranted or accelerated asindicated at block 362.

The oxygenation measurements are continuously updated and monitored atblock 366 as long as a measurement time window has not expired or thearrhythmia has not terminated, e.g., based on EGM signal analysis, asdetermined at block 363. A measurement window set in response to aconcerning arrhythmia may be set to approximately 10 seconds, withoutlimitation. The tissue oxygenation measurements may be updated upon eachsample data point or based on an average or median of multiple sampledata points.

A difference between an updated oxygenation measurement and the episodeonset measurement may then be determined at block 368 as the change inthe measurement since the episode onset. The trend(s) are then comparedto a detection threshold at block 358. The difference may be a trend inO₂Sat (dO_(2Sat)=O₂ Sat_(i)−O₂ Sat_(onset)), HbT(dHbT=HbT_(i)−HbT_(onset)) and/or a TOI (dTOI=TOI_(i)−TOI_(onset)),computed as a function of both O₂ Sat and Hbt. The trend mayalternatively be computed for the uncalibrated indices of O₂ Sat, HbTand/or a TOI computed therefrom, i.e. dSD″(λ) and dD″(λ) and/or dTOIwherein the TOI is computed as a function of both SD″(λ) and D″(λ). Athreshold applied to the trends may be defined for each of theoxygenation measurements independently or a single threshold may bedefined for the TOI. For example, a detection threshold applied todO₂Sat might be defined as a 5% decrease from the onset O-₂Sat. If theonset O₂Sat is 85%, 5% of the onset O₂Sat is 4.25%. As such, if theO₂Sat at onset is 85% and falls to 80% within a 10 second measurementwindow, the dO₂Sat of 5% is greater than the detection threshold of a4.25% decrease resulting in the dO₂Sat detection criteria being met.Other detection thresholds may be similarly applied to the trended HbTand/or TOI measurements.

If the detection threshold(s) defined for the trended measurementscomputed during the concerning arrhythmia episode are met or exceeded,as determined at block 358, the hemodynamic status is detected ashemodynamically unstable at block 360. A shock therapy may be deliveredimmediately or as scheduled at block 361. If the tissue oxygenationmeasurements correspond to adequate or stable tissue oxygenation, thehemodynamic status is detected as stable at block 359. The shock therapyis withheld at block 362.

During baseline comparisons at block 356 and/or application of detectionthresholds at block 358, a posture sensor signal may be provided asinput as indicated by block 355. The posture sensor signal is providedfor selecting the appropriate baseline measurement and/or detectionthreshold to be applied to the oxygenation measurements based on acurrently measured patient posture. For example, if it is determinedthat the patient is in a horizontal position on his stomach,corresponding changes are made to the baseline measurement applied toaccount for the sensed postured of the patient. In one embodiment, forexample, the applied baseline measurement is reduced by a clinicallyestablished amount, such as 5-10 percent.

In some embodiments, detection thresholds may be defined based on aPrincipal Component Analysis (PCA) of the tissue oxygenationmeasurements. PCA involves plotting the O₂Sat and HbT measurements (oruncalibrated indices thereof) in a two-dimensional space (or ann-dimensional space when additional physiological variables are beingused in combination with the oxygenation measurements). A vectoridentifying a first principal component of variation of the plottedmeasurements is computed. The first principal component of variation ofthe measurements may be identified for different types of heart rhythmsand used as a template for detecting a given arrhythmia when the firstprincipal component of the variation of the oxygenation measurementsapproaches a stored first principal component template for the givenarrhythmia.

Additionally or alternatively, a vector identifying a first principalcomponent of variation of the plotted measurements during variousconfounding situations, such as during motion or known patientactivities or postures, may be determined for use in artifact removal.In this case, a principal component that is normal (orthogonal) to thefirst principal component of the plotted measurements in the presence ofartifact can be used to remove the effect of the artifact from themeasurement variation. Principal component analysis methods generallydescribed in U.S. Pat. Appl. No. 61/144,943 to Deno, et al.,incorporated herein by reference in its entirety, may be adapted for usewith the tissue oxygenation measurements described herein. For example,an n-dimensional measurement undergoing PCA may include O₂Sat and HbT orthe uncalibrated values of SD″(λ) and D″(λ) as two of the n dimensions.Alternatively, a TOI computed using a combination of O₂Sat and HbT orSD″(λ) and D″(λ) may be included as one of the n-dimensions combinedwith other physiological variables such a measurement obtained from anEGM signal or other hemodynamic measurements.

If a monitoring window expires at block 363, tissue oxygenationmonitoring may stop at 364. In some embodiments, a monitoring window maybe terminated to prevent prolonged delay of an arrhythmia therapy due totissue oxygenation monitoring. In other embodiments, a new monitoringwindow may be started if the arrhythmia is still being detected.

As long as the detection thresholds are not met at block 358 during themonitoring window, the hemodynamic status is determined to be stable atblock 359, and a shock therapy is withheld at block 362. At block 370,the HbT measurement may be monitored to detect an out of rangemeasurement. Sample data points corresponding to an out-of-range orquestionable value of HbT may be ignored or used to rank the quality ofoxygenation measurements in a measurement correction operation at block372. For example, if a weighted combination of variables is being usedto detect hemodynamic stability/unstability, less weighting may beapplied to HbT (and optionally O₂Sat) when HbT measurement(s) are out ofan acceptable range. HbT may be ignored or assigned a low weightingbased on the range in which the HbT measurement falls. O₂Sat may be usedalone in determining a tissue oxygenation status. If HbT issignificantly out of range for a large number of sample points,detection of a hemodynamically unstable arrhythmia based on oxygenationmeasurements may be disabled. A predetermined number of minimum samplepoints falling within an acceptable measurement range during amonitoring window may be required to rely on the oxygenation-baseddetection algorithm outcome.

FIG. 9 is a time-based plot of response curves for calibrated trends inO₂Sat and HbT during induced VF in a canine subject. The plotted dO₂Satand dHbT are expressed as percentages of baseline measurements.Attenuation spectra were measured at 680 nm, 720 nm, 760 nm and 800 nmand the SD″(720) nm and D″(720) were used to compute calibrated O₂Satand HbT sample points from which the plotted trends were computed. Threedifferent spacings between the light sources and the light detector wereused including 7 mm, 10 mm and 13 mm. The results for the threedifferent spacings are plotted and each show similar trends.

VF induction occurs at time zero. A declining trend in both O₂Sat andHbT is observed beginning at the onset of the induced VF. Usingappropriate detection thresholds applied to the trended variables, forexample in the range of an approximately 2% to an approximately 10%decrease in the trended measurement, hemodynamically unstable arrhythmiacan be confirmed within the first 5 to 10 seconds of the onset of VF.

Response curves similar to those shown in FIG. 9 may be acquired anddisplayed to a clinician during ICD implantation to allow the clinicianto select a sensor implant site, select emitting-to-detecting portionspacings when multiple light sources and/or light detectors areavailable, storing baseline measurements, and setting detectionthresholds. Plots similar to those shown in FIG. 9 may also be generatedusing stored tissue oxygenation data acquired during detected arrhythmiaepisodes for later review and analysis by a clinician.

FIG. 10 is a flow chart of an alternative method 500 for controllingarrhythmia therapy using an optical sensor for monitoring tissueoxygenation. In response to detecting an arrhythmia at block 502 usingother sensor signals, onset tissue oxygenation measurements are obtainedat block 504 as generally described above. At block 506, localelectrical stimulation of tissue adjacent to the optical sensor isinitiated to increase the metabolic demand (the rate of oxygenconsumption by the tissue). Local electrical stimulation of tissuestimulation may be performed using electrodes located along a housingcontaining the optical sensor or using electrodes located on anelectrical lead extending from an optical sensor device or another IMD.Oxygenation measurements may be sampled continuously during the tissuestimulation or obtained at predefined discreet time points or at asingle time point during or upon termination of tissue stimulation.

At block 510, tissue stimulation is stopped. Tissue oxygenationmeasurements are obtained at block 508 for at least one time pointsubsequent to initiating tissue stimulation to allow a rate of tissueoxygenation decline to be determined at block 512. The rate of tissueoxygenation decline may be determined as dO₂Sat, dHbT, dTOI, dSD″(λ),dD″(λ) or any combination thereof and may be determined as a changerelative to the onset measurement.

At block 514, tissue oxygenation measurements may be continued for apredetermined time interval or sampled at one or more discrete timepoints following termination of tissue stimulation. Tissue oxygenationmeasurements are obtained for at least one additional time point afterstopping tissue stimulation to allow a rate of tissue oxygenationrecovery to be determined at block 516. The rate of tissue oxygenationrecovery may also be determined as dO₂Sat, dHbT, dTOI, dSD″(λ), dD″(λ)or any combination thereof. The rate of tissue oxygenation recovery maybe determined as a change relative to the onset measurement, a minimumtissue oxygenation measurement obtained after initiating tissuestimulation, or the tissue oxygenation measurement obtained uponterminating stimulation.

At block 518, the rate of decline and/or the rate of recovery arecompared to previously defined thresholds for detecting ahemodynamically stable arrhythmia. If the rate of decline is less than adetection threshold, and/or the rate of recovery is greater than adetection threshold, the arrhythmia is determined to be hemodynamicallystable at block 520 and a shock may be withheld at block 524. If therate of decline exceeds a detection threshold and/or the rate ofrecovery is less than a detection threshold, the arrhythmia isdetermined to be hemodynamically unstable at block 520. The ICD mayproceed with delivering a scheduled shock therapy at block 522, eitherimmediately or according to a programmed menu of tiered therapies.

Method 500 is not limited to using tissue oxygenation measurementsobtained using an optical sensor capable of measuring light attenuationat four or more wavelengths. In some embodiments, tissue oxygenationmeasurements obtained in combination with local tissue stimulation asdescribed in conjunction with FIG. 10 may include a non-calibrated indexof oxygen saturation determined using a two-wavelength optical sensor,typically emitting and detecting red and infrared light, as generallydisclosed in U.S. Patent Application No. 2007/0255148 (Bhunia), herebyincorporated herein by reference in its entirety. In other embodiments,tissue oxygenation measurements obtained in combination with localtissue stimulation may include non-calibrated indices of oxygensaturation and/or blood volume determined using a two-wavelength(typically red and infrared) optical sensor or a three-wavelength(typically red, isosbestic and infrared) optical sensor as generallydescribed in U.S. Patent Publication No. 2008/0208269 (Cinbis, et al),hereby incorporated herein by reference in its entirety. Non-calibratedtissue oxygenation measurements obtained using two- or three-wavelengthoptical sensors may be substituted for any of the calibratedmeasurements obtained using four or more wavelength sensors describedherein, particularly when a measurement trend is being evaluated over arelatively short period of time, for example, over approximately oneminute or less.

FIG. 11 is a flow chart of a method 600 for detecting a shockable heartrhythm. As used herein, a “shockable” heart rhythm is a rhythm that ishemodynamically unstable. A heart rhythm that is hemodynamically stable(even if compromised) maintains tissue oxygenation at or above anacceptable level (which may be below a “normal” tissue oxygenationlevel). The patient may tolerate a hemodynamically stable rhythm, atleast for a period of time, allowing a shock therapy to be withheld ordelayed.

Upon onset of an arrhythmia, blood pressure may fall to a reduced butstable level while tissue oxygen saturation in the extremities continuesto fall. The stabilized but reduced blood pressure may be the result ofperipheral vasoconstriction that occurs in an effort to maintainperfusion and oxygenation of vital organs. The blood pressure is stablebut the peripheral body tissue (and eventually vital organs) may becomehypoxic.

In other scenarios, blood pressure may fall quickly upon onset of anarrhythmia and then fall at a slower rate. The continued decline inblood pressure is a sign of hemodynamic collapse and will be associatedwith a continued decline in tissue oxygenation.

Blood pressure will correspond generally to the perfusion of the tissueand thus may be correlated to blood volume or Hbt. Tissue oxygen partialpressure will be correlated to tissue O₂Sat. Thus, by monitoring thetrends in O₂Sat and HbT, as well as their absolute values, reliablediscrimination of hemodynamically stable and hemodynamically unstablearrhythmias may be performed.

In method 600, a state table is stored in the memory of an ICD orassociated optical sensing device relating state combinations of O₂Sat,HbT, dO₂Sat and dHbT to a cardiac condition. For example, the absolutevalues of O₂Sat and HbT may classified as high, normal or low accordingto predefined measurement ranges. The trended measurements, dO₂Sat anddHbT, may be classified as increasing, stable or decreasing. For threepossible classifications of each of the four variables of O₂Sat, HbT,dO₂Sat and dHbT, eighty-one possible state combinations exist. Eachstate combination is then defined to be related to a cardiac status. Forexample, each state combination may be stored with an associated cardiacstatus defined as normal, hemodynamically stable but compromised, orhemodynamically unstable. The O₂Sat, HbT, dO₂Sat and dHbT may beobtained without performing an intervention that alters the tissuemetabolic status or with some intervention such as with tissue heating,tissue stimulation, drug delivery or other metabolic or physiologicintervention that alters the state of the tissue or vasculature of thetissue.

An appropriate therapy delivery response for each of the statecombinations may also be stored in the state table at block 602. Forexample, state combinations associated with a normal status may beassigned a withhold therapy response. State combinations associated witha hemodynamically stable but compromised cardiac rhythm status may beassociated with one menu of tiered arrhythmia therapies, e.g. excludinga shock delivery, and hemodynamically unstable state combinations may beassociated with a more aggressive menu of tiered arrhythmia therapies orimmediate shock delivery.

The state table may further include the status or classification ofother sensor signals. For example, arrhythmia detection status based ona primary arrhythmia detection sensor signal, such as an EGM or ECGsignal, temperature status, activity status, posture status, or anyother physiological signal status may be combined in the state tablewith the tissue oxygenation measurements for determining a cardiacstatus and associated therapy selection and sequencing. In addition tostoring a therapy response, certain state combinations may additionallyor alternatively be stored with a device response that includesadditional detection, discrimination or diagnostic algorithms to beperformed using other sensor signals, different signal processing andanalysis methods, and/or include metabolic or physiological perturbationof the tissue, such as tissue stimulation or tissue heating.

At block 604 an arrhythmia may be detected using a primary detectionparameter, such as an EGM/ECG signal. At block 606, onset tissueoxygenation measurements are performed, upon detecting an arrhythmia atblock 604. Alternatively, tissue oxygenation monitoring as described atblocks 606 through 612 is performed on a continuous basis for useinitially detecting a cardiac arrhythmia or an initial cardiac status. Amonitoring interval may be defined, which may be approximately 2seconds, up to approximately 20 seconds or any interval there between,such as approximately 3 seconds, 5 seconds, 10 seconds or 15 seconds. Insome applications, even longer monitoring intervals may be applied,e.g., up to approximately one minute. At the beginning of the monitoringinterval, the onset oxygenation measurements are acquired at block 606.

At block 608, tissue oxygenation measurements are obtained at one ormore time points later than the onset time point and during, or at theend of, the monitoring interval. At least one later measurement for eachof O₂Sat and HbT is used to determine dO₂Sat and dHbT, respectively atblock 610. At block 612, the absolute O₂Sat and HbT measurements thatwas obtained at one or more selected time points (onset of a monitoringinterval, end of a monitoring interval, or therebetween) are classifiedaccording to the possible state table classifications (e.g. high, low,or normal). Likewise the dO₂Sat and dHbT measurements are classifiedaccording to the possible state table classifications (e.g. increasing,stable or decreasing). A cardiac rhythm status is determined at block612 by looking up the status stored with the associated combination ofmeasurement classifications.

As indicated by block 612, other sensor parameter statuses (e.g.,temperature, activity, posture, heart rate, etc.) may be provided asinput for looking up the cardiac rhythm status in the state table. Atblock 614, the implantable medical device provides a response based onthe identified cardiac rhythm status. As discussed above, the responsemay include withholding a therapy, selecting a particular menu of tieredtherapies, progressing immediately to shock delivery, executingadditional detection, discrimination or diagnostic algorithms, orgenerating a patient/clinician notification.

Thus, a medical device and methods for use have been presented in theforegoing description with reference to specific embodiments. It isappreciated that various modifications to the referenced embodiments maybe made without departing from the scope of the disclosure as set forthin the following claims.

1. An implantable medical device, comprising: a cardiac electrode forsensing cardiac depolarization signals; an optical sensor for providinga signal corresponding to light attenuation by a volume of bloodperfused tissue; a control module coupled to the optical sensorcontrolling the light emitted by the optical sensor; a monitoring modulereceiving an optical sensor output signal and measuring lightattenuation; a tissue electrode for stimulating the volume of bloodperfused tissue; a pulse generator coupled to the tissue electrode fordelivering electrical stimulation to the volume of blood-perfusedtissue; and a processor coupled to the cardiac electrode and themonitoring module and configured to detect an arrhythmia in response tothe depolarization signals, compute a tissue oxygenation measurement inresponse to detecting the arrhythmia, control the pulse generator todeliver electrical stimulation to the volume of blood-perfused tissue inresponse to detecting the arrhythmia, determine one of a rate of tissueoxygenation decline and a rate of tissue oxygenation recovery, anddetect a hemodynamic status of the arrhythmia in response to at leastone of the rate of tissue oxygenation decline and the rate of tissueoxygenation recovery.
 2. The device of claim 1, further comprising atherapy delivery module coupled to the electrode to deliver shocktherapy for treating the arrhythmia, wherein the processor is furtherconfigured to detect the hemodynamic status as unstable in response to adecreasing measure of tissue oxygenation and to enable the therapydelivery module to deliver the shock therapy in response to detectingthe unstable hemodynamic status, and withhold delivery of a shocktherapy by the therapy delivery module in response to not detecting thehemodynamic status as unstable.
 3. The device of claim 1, wherein themonitoring module monitors a signal from the optical sensorcorresponding to light attenuation of at least four spaced apart lightwavelengths, and wherein the processor is further configured to computean attenuation for each of the at least four wavelengths of detectedlight, compute a second derivative of the light attenuation with respectto two different wavelengths, and compute a measure of tissue oxygensaturation as a ratio of the second derivatives at the two differentwavelengths.
 4. The device of claim 3, wherein the processor is furtherconfigured to compute a measure of total hemoglobin volume fractionusing the measure of tissue oxygen saturation, and detect a hemodynamicstatus in response to both the measure of tissue oxygen saturation andthe measure of total hemoglobin volume fraction.
 5. The device of claim1, further comprising a therapy delivery module coupled to the electrodefor delivering shock therapy to a patient, wherein the processor isfurther configured to determine a baseline measurement of tissueoxygenation prior to detecting the arrhythmia, compute an onsetmeasurement of tissue oxygenation corresponding to a time at which thearrhythmia is detected in response to the depolarization signals,compare the baseline measurement and the onset measurement, and enablethe therapy delivery module to deliver shock therapy in response to theonset measurement being less than the baseline measurement.
 6. Thedevice of claim 1, further comprising a therapy delivery module coupledto the electrode for delivering shock therapy to a patient, wherein theprocessor is further configured to determine an onset measurement oftissue oxygenation corresponding to a time at which the arrhythmia isdetected in response to the depolarization signals, compute an episodemeasurement of tissue oxygenation corresponding to a time subsequent tothe arrhythmia being detected in response to the depolarization signals,compare the onset measurement and the episode measurement and enable thetherapy delivery module to deliver a shock therapy in response to theepisode measurement being less than the onset measurement.
 7. The deviceof claim 3, further comprising a memory storing an acceptablemeasurement range for the measure of total hemoglobin volume fraction,wherein the processor is further configured to compare the measure oftotal hemoglobin volume fraction to the acceptable measurement range,and determine a quality of the measure of total hemoglobin volumefraction and the measure of tissue oxygen saturation in response to thecomparing.
 8. The device of claim 1, further comprising a memory forstoring a threshold, wherein the processor is further configured todetermine a baseline measurement of tissue oxygenation prior todetecting the arrhythmia, compute a threshold in response to thebaseline measurement and store the threshold in the memory; and comparethe measure of tissue oxygenation to the threshold.
 9. The device ofclaim 3, wherein analyzing the measure of tissue oxygen saturation andthe measure of total hemoglobin volume fraction comprises computing atissue oxygenation index as a function of the measure of tissue oxygensaturation and the measure of total hemoglobin volume fraction.
 10. Thedevice of claim 1, further comprising a sensor coupled to the processorto sense a signal corresponding to a patient position, wherein theprocessor is further configured to detect the hemodynamic status inresponse to the measure of tissue oxygenation and the signalcorresponding to the patient position.
 11. The device of claim 1,further comprising a memory storing a state table relating the tissueoxygenation measurement to a cardiac status, wherein the processor isfurther configured to determine an absolute value of the tissueoxygenation measurement and a trended value of the tissue oxygenationmeasurement, and detect the hemodynamic status by determining a cardiacstatus stored in the state table corresponding to the absolute value andthe trended value.
 12. A method, comprising: sensing cardiacdepolarization signals; detecting an arrhythmia in response to thedepolarization intervals; generating a signal corresponding to lightattenuation corresponding to a volume of blood perfused tissue;determining a light attenuation in response to the generated signal;delivering electrical stimulation to the volume of blood-perfused tissuein response to detecting an arrhythmia; determining a tissue oxygenationmeasurement in response to detecting the arrhythmia; determining one ofa rate of tissue oxygenation decline and a rate of tissue oxygenationrecovery in response to the delivered electrical stimulation; anddetecting a hemodynamic status of the arrhythmia in response to at leastone of the rate of tissue oxygenation decline and the rate of tissueoxygenation recovery.
 13. The method of claim 12, further comprising:detecting the hemodynamic status as unstable in response to a decreasingmeasure of tissue oxygenation; delivering shock therapy in response todetecting the unstable hemodynamic status; and withholding delivery ofshock therapy in response to not detecting the hemodynamic status asunstable.
 14. The method of claim 12, further comprising: monitoring thesignal corresponding to light attenuation of at least four spaced apartlight wavelengths; determining an attenuation for each of the at leastfour wavelengths; determining a second derivative of the lightattenuation with respect to two different wavelengths; and determining ameasure of tissue oxygen saturation as a ratio of the second derivativesat the two different wavelengths.
 15. The method of claim 13, furthercomprising: determining a measure of total hemoglobin volume fraction inresponse to the measure of tissue oxygen saturation; and detecting ahemodynamic status in response to both the measure of tissue oxygensaturation and the measure of total hemoglobin volume fraction.
 16. Themethod of claim 12, further comprising: determining a baselinemeasurement of tissue oxygenation prior to detecting the arrhythmia;determining an onset measurement of tissue oxygenation corresponding toa time at which the arrhythmia is detected; comparing the baselinemeasurement and the onset measurement; and delivering shock therapy inresponse to the onset measurement being less than the baselinemeasurement.
 17. The method of claim 12, further comprising: determiningan onset measurement of tissue oxygenation corresponding to a time atwhich the arrhythmia is detected; determining an episode measurement oftissue oxygenation corresponding to a time subsequent to the arrhythmiabeing detected; comparing the onset measurement and the episodemeasurement; and delivering shock therapy in response to the episodemeasurement being less than the onset measurement.
 18. The method ofclaim 15, further comprising: storing an acceptable measurement rangefor the measure of total hemoglobin volume fraction; comparing themeasure of total hemoglobin volume fraction to the acceptablemeasurement range; and determining a quality of the measure of totalhemoglobin volume fraction and the measure of tissue oxygen saturationin response to the comparing.
 19. The method of claim 12, furthercomprising: determining a baseline measurement of tissue oxygenationprior to detecting the arrhythmia; determining a threshold in responseto the baseline measurement; and comparing the measure of tissueoxygenation to the threshold.
 20. The method of claim 15, furthercomprising determining a tissue oxygenation index as a function of themeasure of tissue oxygen saturation and the measure of total hemoglobinvolume fraction.
 21. The method of claim 12, further comprising: sensinga signal corresponding to a patient position; and detecting thehemodynamic status in response to the measure of tissue oxygenation andthe signal corresponding to the patient position.
 22. The method ofclaim 12, further comprising: determining an absolute value of thetissue oxygenation measurement and a trended value of the tissueoxygenation measurement; and detecting the hemodynamic status bydetermining a cardiac status stored in a state table corresponding tothe absolute value and the trended value.
 23. A computer readable mediumhaving computer executable instructions for performing a methodcomprising: sensing cardiac depolarization signals; detecting anarrhythmia in response to the depolarization intervals; generating asignal corresponding to light attenuation corresponding to a volume ofblood perfused tissue; determining a light attenuation in response tothe generated signal; delivering electrical stimulation to the volume ofblood-perfused tissue in response to detecting an arrhythmia;determining a tissue oxygenation measurement in response to detectingthe arrhythmia; determining one of a rate of tissue oxygenation declineand a rate of tissue oxygenation recovery in response to the deliveredelectrical stimulation; and detecting a hemodynamic status of thearrhythmia in response to at least one of the rate of tissue oxygenationdecline and the rate of tissue oxygenation recovery.